Provider Demographics
NPI:1932947397
Name:CUEVAS, MARIO ROBERTO
Entity type:Individual
Prefix:
First Name:MARIO
Middle Name:ROBERTO
Last Name:CUEVAS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3587 SWEETWOOD ST
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93063-2535
Mailing Address - Country:US
Mailing Address - Phone:661-388-7020
Mailing Address - Fax:
Practice Address - Street 1:333 N LANTANA ST STE 259
Practice Address - Street 2:
Practice Address - City:CAMARILLO
Practice Address - State:CA
Practice Address - Zip Code:93010-9008
Practice Address - Country:US
Practice Address - Phone:820-426-1545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-18
Last Update Date:2024-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker